March 10, 2010

As demonstrated by this amateur video from the Atlanta Olympic bombing, the automatic fear response involves crouching and vigilance (everyone looking around). After a few seconds, as the frontal lobes kick in, those who felt closest to danger fled. This video was alluded to in last night's excellent talk by Joe LeDoux.

March 2, 2010

In a relatively short period of time, medicine has grown infinitely complex. Specialties have splintered into subspecialties. The number of diagnostic tests, available treatments, and knowledge about diseases has exploded. But as often reported, the complexity - not to mention the cost to deliver it - has not necessarily improved outcomes.

In The Checklist Manifesto, Atul Gawande offers a bafflingly simple idea to tame the complexity and to bring more discipline to medicine: checklists. He believes the use of checklists can standardize the delivery of care and ensure that proven treatments are actually delivered. He draws mostly from his experience in the OR, where he has found that checklists save more lives than surgery can alone.

It's easy to be dismissive about his idea. Aviation, his favored checklist-heavy profession, is very different from treating individual patients. Doctors need the flexibility to react to conditions as they change, not the rigidity of a checklist. But in the chaos of the OR, a checklist doesn't only ensure that life-saving antibiotics are delivered before an operation or the correct side is operated on. Checklists encourage communication among the entire team and get the easy stuff out of the way so the team can focus on the job at hand.

Checklists are a way to inject discipline and teamwork into a profession where the hierarchical delivery of care doesn't encourage checks. At this time there is little guarantee that advances in knowledge are applied in every appropriate clinical setting. After years of rigorous training, residents enter busy practices in sometimes rapidly evolving fields. For the most part they function autonomously in outposts all over the country where the newest data isn't always folded into their practice. That doctors often learn about new therapies from pharmaceutical reps is another problem. Continuing medical education requirements shoulder some of the burden of keeping doctors up to date, but there is no equivalent to the updated flight manuals provided to pilots on a regular basis.

The body of medical knowledge has exponentially increased, but the culture of medicine has not. As other industries have made leaps in efficiency, many hospitals are still using paper charts. Dr. Gawande is really suggesting an inroad into the morass of complexity. Checklists could serve to change the culture of medicine by introducing more discipline and teamwork. This in turn would spawn efficiency and standardization which would hopefully lead to the holy grail of medicine, improved outcomes. In his book Dr. Gawande shares evidence that, at least in surgery, checklists alone improve outcomes.

When patient care doesn't go by the book, physicians remind themselves that, after all, it is "the art of medicine". The problem is when the art is left to chance and prone to inconsistency. Checklists might just make the art better.